Sequential structures and categorical implications in doctor-patient interaction:

ethnomethodology and history*

by Paul ten Have, University of Amsterdam

12 August 2002

Introduction: ethnomethodology and conversation analysis

Before I start with my core arguments, I need to offer a short explication of my general approach, which is inspired by the twin traditions of ethnomethodology and conversation analysis.

Stated in broad terms, ethnomethodology has, in the first place, been a new way of conceiving sociology's problems, which has lead, secondly, to new ways of studying sociology's phenomena. As a first approximation(2), one can say that 'ethnomethodology' (EM) is a special kind of social inquiry, dedicated to explicating the ways in which collectivity members create and maintain a sense of order and intelligibility in social life. It has emerged as a distinctive perspective and style of social research in the oeuvre and teaching of one man, Harold Garfinkel. From a varied set of 'sources of inspiration', including on the one hand most prominently his teacher and PhD supervisor Talcott Parsons, and on other the phenomenological philosophies of Alfred Schutz, Aron Gurwitsch and Edmund Husserl, he has forged a new vision of what social inquiry could be. Taking off from Parsons' impressive synthesization of various classical traditions of sociological theorizing and research, one can say that in ethnomethodology, these have been turned on their heads. For the Durkheimian strand in classical sociology, and social research more generally, the ultimate goal is to investigate 'social facts', and their determinants, where 'social facts' have the twin characteristic of being both 'external' and 'constraining' to the actions of individuals. In ethnomethodology, on the other hand - to adapt a phrase from Melvin Pollner (1974) - 'facts are treated as accomplishments', that is, they are seen as being produced in and through members' practical activities.

In other words, while classical (Durkheimian) sociology is in the business of explaining social facts, the effort of ethnomethodology is directed towards an explication of their constitution. In his Le suicide: Étude de sociologie, Emile Durkheim tried to explain variations in suicide rates in terms of variations in kinds of social integration. An ethnomethodologist, however, might investigate the ways in which cases of sudden death get constituted as being 'suicides', or, at a different level, how statistical information about various 'rates' is used to construct a sociological explanation of suicide in terms of social 'causes'(3).

For sociology, and social research in general, the interest in the factual status of 'social facts' is limited to technical and practical issues of getting those facts right, in a methodologically sound way, and at reasonable costs. For ethnomethodology, to use a contrast that has become quite famous, the interest is not so much in various research practices to be used as a resource as well as being a topic for research in their own right. Ethnomethodology's relationship with its 'mother discipline' sociology, and by extension to all 'social science', is then rather ambiguous. Both share a deep interest in problems of social order and try to elucidate the organization of social life in all its manifestations. But their general approach is tangential one to the other. I would like to stress that this 'tangentiality' should not in the first place be seen as a difference in 'research methods', as ordinarily conceived, but, as suggested above, as one of 'interests' and 'problematics'.

For this paper, a full sketch of ethnomethodology's background is obviously not possible. I can only provide some rough indications of the complex intellectual network involved in its emergence (or rather creation). I have focussed above on the contrast of ethnomethodology with a loosely defined Durkheimian sociology, as exemplified to a certain extent in the oeuvre of Garfinkel's teacher, Talcott Parsons. It should be noted, however, that there is (much) more in Parsons than 'just' Durkheim. In fact, the influence of Max Weber is equally important for an adequate understanding of Parsons, and therefore of Garfinkel and ethnomethodology. A major aspect of Weber's sociology is that it is based on a specific conception of meaningful social action. This meaning needs to be 'understood' before such an action can figure in any sociological argument. 'Understanding' (verstehen) in this context does not refer to some kind of intuitive empathy, but rather to a process of rational reconstruction of the sense of actions by the analyst in terms of 'ideal types'. This overall approach has been subjected to a philosophical critique by Alfred Schutz, taking his inspiration from previous philosophers like Edmund Husserl and Henri Bergson. One point of Schutz was that the use of ideal types is not just the way in which a verstehende sociologist reconstructs the sense of actions, but that typification is an unavoidable aspect of everyday life, especially when people are not in direct contact with each other. Harold Garfinkel used the insights of Schutz and other phenomenological philosophers such as Aron Gurwitsch, in his intellectual struggle with the Parsonian heritage, but at the same time he departed from these phenomenological ideas in important ways. In the ethnomethodological program, the foundation for a critique of Weber or Parsons is no longer an in-depth analysis of the constitution in individual consciousness of various kinds of social knowledge. Instead, the focus is on social procedures used to establish and maintain 'a sense of social structure', i.e. an intelligible and accountable local social order. What is kept from phenomenology, then, includes a stress on taken-for-granted knowledge and a deep interest in the local constitution of practical activities in everyday life.

In contrast to both Parsons and Schutz, ethnomethodology does not make a sharp distinction between the general stance and rationality of on the one hand science and on the other everyday life. In fact, it suggests that the activities of scientists are in many ways similar to ordinary lay activities. There are two sides to this major point. On the one hand, ethnomethodology has a deep interest in and respect for the practical rationality and accountability of the most commonplace of ordinary activities. The very label of 'ethnomethodology' was coined by Garfinkel when he was involved in a study of jury deliberations and was struck by the seriousness of the 'methodology' those 'lay' deliberations displayed. And on the other hand, ethnomethodology has studied various scientific practices to understand their grounding in local rationalities that are in many ways similar to those used in everyday life. The crux of the matter is that while Weber, Schutz and Parsons discuss idealized models of science and scientific rationality, ethnomethodology is geared to study the local accountability of any kind of practice. This way of making science ordinary does not mean that ethnomethodology is blind to the specifics of particular professional practices, such as doing disciplined research. To the contrary, by following professional practices in detail, ethnomethodology can do two things at the same time: show that and how a professional practice is embedded in quite ordinary competences, and also elaborate that and how it is special, in the sense of being part of a particular local version of a more generalized professional culture.

Harold Garfinkel's major and most influential publication, Studies in Ethnomethodology, published in 1967, collects 8 papers written over a 12 year period. In it, one can trace some aspects of his reworking of the above named 'influences', especially that of Alfred Schutz. His then current position is most clearly expressed in the preface and first chapter, and illustrated in the next two chapters. After 1967, Garfinkel has not published very much, one very important paper with Harvey Sacks (1970), two papers written in collaboration with two of his former students, Eric Livingston and Michael Lynch (1981, 1983), and a series of overlapping programmatic statements, published from 1988 onwards (1988, 1991, 1996). Some of this work has been included in his just published second book (Garfinkel, 2002), but it was not yet available at the time of writing of this essay. Garfinkel's pervasive influence has been mostly based on his 1967 book, while it has also partly had its effect through his students and collaborators. Although Garfinkel's initiatives, and ethnomethodology generally, have had a discernable impact on sociology, the number of people actually doing ethnomethodological studies is still rather limited.

The most famous of Garfinkel's early collaborators has been Harvey Sacks, who together with some others, notably Emanuel Schegloff and later Gail Jefferson, developed an approach of his own, now called Conversation Analysis (CA). Schegloff, Jefferson, and a number of others have continued to develop CA further after Sacks' early death in 1975. From the mid-1970s onwards, the number of practitioners of CA has been growing and now clearly outnumbers those who do ethnomethodological studies in a style closer to Garfinkel's inspiration. As I have treated the general character of CA and its development quite extensively elsewhere (Ten Have, 1999), my discussion here will be limited. CA's specific focus on the local organization of talk-in-interaction emerged from a wider set of concerns raised by the detailed inspection of transcribed fragments of 'conversation' (cf. Sacks, 1992). Two major themes were present right from the beginning: the local use of common sense knowledge as organized around categories of persons, and the sequential organization of conversation. The first theme, together with a larger set of issues concerning 'mind' and 'knowledge' receded in the background, while the second became the dominant one and is now CA's hallmark.

While Sacks and Schegloff, in their early work, mostly used data from institutional settings - calls to a suicide prevention centre, group therapy sessions and calls to a disaster centre - their analyses focussed on generic features of the talk, mostly ignoring the institutional context. In later work, they tended to use data from 'ordinary conversations' - mundane and informal talk between peers. From the late 1970s onward, a number of CA researchers have returned to 'institutional talk', using the generic finding of CA as a backdrop for their research into the specific properties of talk in various institutional settings such as courtrooms, medical consultations or news interviews (4)

While a lot of CA work has been based on recorded telephone conversations, audio recordings of face-to-face interactions - such as the group therapy sessions, mentioned above - were also used. A basic problem with the latter analyses was, of course, that non-vocal parts of the interactions were not recorded and were therefore not available for analysis. By using video equipment, researchers like Charles Goodwin and Christian Heath have extended CA's grasp to include visual aspects of interaction, at first aspects of bodily comportment like gaze shifts, later also actions like the manipulation of objects, the reading of screens and the typing on keyboards. This has allowed the intensive study of complicated work settings in so-called workplace studies.

Within the by now quite large corpus of CA studies, a substantial number of papers and books have been devoted to the study of doctor-patient interactions. This subfield has been at first explored by Richard Frankel (1984, 1990, a.o.), and Christian Heath (1984, 1986, 1988, 1989, 1992), while others have also made substantial contributions. A larger part of my own work in CA has been on medical consultations in the context of general practice or 'family medicine' (1987, 1989, 1990, 1991, 1993, 1995b) (5). Some of my core ideas on the subject, which are partly based in this literature, and partly on my own research, will be discussed in the following section.

The 'ideal sequence' of GP consultations

In this section, I propose that the basic format of the medical consultation consists of a typical sequential structure, or, as I call it, an Ideal Sequence, as follows:

1. opening
2. complaint
3. elaboration, examination end/or test
4. diagnosis
5. treatment and/or advice
6. closing

This proposal was one of the results of my conversation-analytic research, which involved a detailed inspection of a substantial number of audio-recorded GP consultation that had been taking place in the late 1970s in the Netherlands (Ten Have, 1987, 1989). The sequence is called 'ideal' because it is in many cases not actually descriptive of the in fact realized sequential structures, but rather indicative of a general trend in their organization. One can observe many deviations from it that seem to be quite acceptable to the participants, but they do demonstrate a general orientation to such an organization. It often happens, for instance, that during a later phase they return to an earlier one, especially when problems arise later on. It should be noted that phases 2 to 5, which are the ones specific for the occasion, usually include some sort of 'discussion' of what is proposed or done, leading to some sort of accordance, as when a patient accepts a diagnosis or agrees to a treatment.. The physician, in most cases, is the one in charge of the proceedings, the one who initiates the various steps, with the patient following him. Similar schemes have been formulated in the literature (for instance, Byrne and Long, 1976:21).

I base my proposal on three kinds of argument: firstly, the empirical argument that the Ideal Sequence corresponds approximately with what goes on during most consultations; secondly, the analytic argument that the Sequence can be analysed in terms of the 'logic' implied in the consultations as a specific kind of service provision established in society; and finally, the empirical argument that participants display an orientation to a Sequence such as this one in the details of their interaction (ten Have, 1987:103-141).

I now offer a summary description of the typical progression of a consultation. The physician acts as a host who receives the patient as his or her guest for a meeting at the latter's initiative and with a restricted purpose. At the start of the encounter the host receives the guest, offers greetings, invites him or her in, offers a seat, and may make some initial inquiries or comments regarding non-professional, i.e. non-medical, matters. The guest reciprocally greets, accepts to enter and sit down and may also make inquiries or give comments of a social nature. Those activities constitute the opening phase of the encounter and are oriented to general principles of polite interaction.

The opening phase usually ends when the physician displays his or her readiness to receive expressions of the patient's reason to visit the GP this time. Asking for an appointment or sitting in the waiting room at the doctor's office hour implies a claim for medical attention, and this claim has now to be accounted for. In my 70s materials, this is mostly done by describing symptoms, voicing complaints and/or asking the physician to 'look at' certain body parts. In general these presentations are quite concise and dense, as summaries that invite unpacking (cf. Jefferson, 1985). This second phase passes on to a third one when the physician starts to ask questions that request elaboration or ask for specific details or symptoms.

In so doing, the presentation is elaborated through what is often called a verbal examination, which may be followed by a physical examination and/or some testing. During this phase, one can quite often discern a slight tension between the patient wanting to tell his or her story and the physician following his or her professional agenda of checking alternative diagnoses. Most often, the physician receives the patient-provided information in a non-committal manner (as in 'uhuh', 'okay', 'yes').

At a certain moment the physician will take the floor to announce his conclusions, mostly first a diagnosis, followed by a treatment proposal or advice, constituting phases 4 and 5. As suggested above, these conclusions tend to be discussed at some length, seemingly requiring some kind of acceptance by the patient. When this is achieved, the closing phase can be initiated, generally consisting of arrangements, well-wishes, thanks and greetings. One could say that the medical framework is gradually loosened up, leading to a social leave-taking, as the host accompanies his or her guest to the door.

I think this progression of phases can be understood in terms of a combination of several sequential 'logics'. As suggested as part of my description above, the opening and closing phases can be seen as being formatted in terms of a generalized 'polite' routine of opening and closing encounters. During these phase, the two parties mostly enact the categories of 'host' and 'guest'. Within these social 'brackets', the consultation is formatted as a service encounter, starting with a request-for-service in phase 2, and ending with a service-delivery in phases 4 and 5. As noted, the request in phase two tends to be implied in a description, rather than being fully explicated. And in those cases in which a request is made, it tends to be one for an investigation. In other words, whether the patient wants a diagnosis, or a treatment, or both, is generally not made explicitly clear. Of course diagnosis and treatment/advice can be seen as mutually implicative, i.e. a diagnosis leads to certain treatment options, while a treatment requires a diagnosis as an account of its sense. But in any case, a patient may get a service that is not requested nor wanted. This leaves us with phase 3, elaboration, examination and/or test. What happens in this phase can best be seen in terms of (a series of) insertion sequence(s). It has been observed in many kinds of service encounters that the customer is requested to provide various kinds of specifications of the problem and/or its circumstances, before a fitting solution is provided.

Combining the conventional phase progression with the above remarks on their underlying 'logic', I propose the following schema:

An Ideal Sequence for GP encounters
1 opening
2              complaint                                                                                              implicit double request
3                              elaboration, examination end/or test                                             insertion sequence
4              diagnosis                                                                                                                response 1
5              treatment and/or advice                                                                                          response 2
6 closing

In this schema, italic marks the 'social' character of the first and last phases. The column positions indicate which phases are constitutive of which sequence types: the embedding social sequence, the core request sequence, or the inserted elaboration sequences. The right-hand column provides a summary characterization.

The logic of the consultation, as suggested here, is based on a set of assumptions regarding professional practice which is re-affirmed in the way in which the consultation is formatted. It takes place within the territory of the physician, putting the patient into a guest position with the physician acting as a host. The core of the encounter, however, tends to enact another contrast, between the lay patient and the professional physician. The reason for an accountable visit is a concern of the patient, a (possible) medical problem which is not solvable by the ordinary means that are at the disposal of lay persons, and therefore is a candidate for professional action. In fact, many patients report that they have first tried some household remedy, before deciding to consult the doctor. It seems to me that the subdued way in which most patients formulate their problem, by descriptions using ordinary language and simple 'looking-requests', is a further enactment of the lay/professional contrast. It is up to the professional to start the explication of the problem, after some first indications provides by the lay person.

Underlying the sequential structure of the consultation, then, is a shared although complementary orientation to a specific type of Membership Categorization Device, a Standardized Relational Pair (cf. Sacks, 1972), consisting of two categories, 'doctor' and 'patient'. As members of society, incumbents of those categories, as well as others, know which kinds of actions, knowledge, competencies, duties, etc. are expectable for each party in the pair. This general members' knowledge is used and relied on in each actual occasion in which it is relevant, but in so doing the actual category predicates are, most often in passing, re-negotiated. Therefore, the ethnomethodological perspective suggests that structures of action, like the Ideal Sequence discussed above, are being re-constituted on each and every occasion of their occurrence. Society is continuously made to happen again.

Negotiating the 'normal form'- 1: a case from the 70s

From an ethnomethodological point of view, specifying a 'structure', as the Ideal Sequence discussed in the previous section, is only a part of the task at hand. So what I will do now is to use these ideas as a background for a discussion of some extracts from a consultation recorded in the late 1970s in the Netherlands, which I have discussed at greater length elsewhere (Ten Have, 1998) (6). I will especially focus on some interesting moments of implicit negotiations about the local progression of the encounter, or as I would like to suggest, the local relevance of the Ideal Sequence.

In this encounter, a mother consults for and with her 9 years old daughter. After the opening, the mother presents the case in quite ordinary, 'lay' terms as follows in extract 1.1

Extract 1.1

10 M: e:h ik kom met Liesbeth,
10 M: uh I'm coming with Lisbeth
11 M: die is de laatste tijd vreselijk moe.
11 M: she is terribly tired of late
12 (0.4)
13 M: die klaagt maar over moe,
13 M: she keeps complaining of being tired
14 (1.4)
15 M: en laatste dagen is ze maar draa:ierig
15 M: and the last few days she keeps being giddy
16 M: en:: ja >is ze al een paar dagen niet< naar school geweest
16 M: and yes she hasn't been to school for a few days
17 M: en >deh-k ja ben je nou ziek of ben je niet ziek<
17 M: and I tho- yes are you ill or aren't you
18 M: hoofd- ze heeft t-toch altijd vrij veel hoofdpijn,
18 M: head- she suffers always quite a bit from headaches
19 (0.3)
20 M: klaagt ze wel meer over,
20 M: she does complain about that regularly
21 (0.5)
22 M: en nu is ze de laatste dagen nogal draaierig.=
22 M: and now the last few days she is quite giddy
23 M: =ze eet dus ook niet veel,=
23 M: she doesn't eat much either
24 M: =>ze- maar ze he-
24 M: she- but she ha-
25 M: ze is niet koortserig<
25 M: she is not feverish
26 M: of grie[perig verder?
26 M: or flulike for the rest
27 A:             [nee.
27 A:            [no
28 (2.2)

After this, the physician request the child to show him her tongue. As this is done, the mother adds some further descriptions of her child's behaviour. Then the physician asks the child whether she has any pains, and at her response he proceeds as follows:

Extract 1.2

54 A: 'hh nou we zullen es kijken,
54 A: 'hh well we will take a look
55 A: d't kan eh (0.5) eenvoudig (0.9) 'te zijn=
55 A: it can uh (0.5) simply (0.9) be
56 A: =>dat ze (bevoorbeeld) wat tekort aan bloed heeft.<
56 A: that she has for instance a little blood shortage
57 A: ze is [negen jaar,
57 A: she is [nine years
58 M:        [(°ja heb ik ook al°)
58 M:        [(°yes I have also already°)
59 A: 'hhh de leeftijden één jaar vier jaar negen,
59 A: 'hhh the ages one year four years and nine
60 A: ja tieelf >zo'n beetje rond-tie tijd,=
60 A: yes ten eleven araound that time
61 A: =als ze een beetje< uit gaan schieten.
61 A: when they begin to grow
62 A: 'hhh dat zijn >tijden waarop kinderen vaak=
62 A: 'hhh those are times when children often
63 A: =een beetje bloedarmoede [hebben.
63 A: have a little blood sh[ortage
64 M:                                              [(jjjh) twee jaar >geleden=
64 M:                                             [(jjjh) two years back
65 M: =heeft ze 't ook gehad,=
65 M: she also had that
66 M: =toen ook in september,=
66 M: also in September then
67 M: =toen waren we bij de schoolarts,=
67 M: when we visited the school doctor
68 M: =en toen had ze ook bloed[armoede.<
68 M: =and she also had a blood [shortage then
69 A:                                               [hmm
69 A:                                              [hmm
70 (1.6)
71 A: >'k wee- niet of het wat is=
71 A: I don't know whether it's something
72 A: =maar we kunnen ('t) even (prikken).<
72 A: but we can just prick
73 (1.4)

So we can say that after the 'complaint' in phase 2 (cf. Extract 1.1), the physician proceeds to phase 3, elaborating the complaint and examining the case. It is remarkable, but far from exceptional, that the mother offers unsolicited expansions of the complaint description. Then the physician announces an examination (55) and presents his provisional diagnosis (56), followed by some further remarks. The mother, however, adds her own comments to the effect that she was expecting just this, because her child has been suffering from the same ailment earlier (64-69). The physician limits his engagement with this to an acknowledgment (69) and, after a pause (70), stresses the provisional status of his diagnosis and re-announces the examination (72).

To my mind, this episode is remarkable in a number of respects. Firstly, there is the fact that the physician, while announcing a test, and thus marking the current phase as incomplete, already presents a provisional diagnosis. It has been suggested that such 'online commentaries' may fit into a defensive strategy of a physician, as he or she suspects that he may have to come up with a diagnosis or treatment that is somehow 'less' than the patient seems to expect or want (Heritage & Stivers, 1999). The formulation 'it can uh (0.5) simply (0.9) be that she has for instance a little blood shortage' (55-6) seems to support its 'down-grading' quality, as does his further explication of a little blood shortage as a 'normal' phenomenon for that age group (57, 59-63).

Secondly, it is remarkable that the mother, upon hearing the physician's provisional diagnosis, comes in with the announcement that she had been thinking likewise (58), followed - after the doctor has explicated an age-related pattern (59-63) - with the further elaboration that her daughter has suffered from the same ailment before (64-68). That is, as soon as the physician has expressed his view, she comes forward with her view, which she has kept for herself until now, restricting her earlier contributions quite strictly to lay descriptions of symptoms. In a sense, then, expressing her lay diagnosis has come remarkably late in the encounter, but at the same time she proffers it early in relation to the previous utterance by the physician, in overlap with the start of his elaboration of the diagnosis. In this fashion, she demonstrates that her recognition of his diagnosis was available for immediate production, that the diagnosis was 'on her mind'. At the same time, however, she produces it in a subdued manner, in a soft voice and breaking it off before it is finished. While this way of speaking may be seen as a display of modesty at her suggesting an assessment belonging to the other's professional authority, it is, at the same time, a demonstration of spontaneity. It is produced as an utterance which 'escaped' her.

Thirdly, when the physician's age-related explanation turns to a close (63), she immediately in overlap comes in with an account of her earlier 'recognition' in that her daughter has suffered earlier from a blood shortage two years ago exactly (64-68). She repeatedly stresses the also and mentions that another physician, a school doctor, has done the diagnosis then. In other words, she explicates the 'grounds' of her lay diagnosing, referring both to her previous experience as a mother and to the professional who did the diagnostic work at the time. There is, however, no real uptake from the physician (cf. 69), and after a substantial pause he recycles his intention to do a blood test, formulated in a rather hedged manner: I don't know whether it's something but we can just prick (70-71).

After this, the physician tries to question the daughter who only gives minimal answers, while sometimes the mother adds descriptions. There are sounds of writing. Then the phsycian clearly marks the end of this verbal examination by inviting the girl to come with him for the test. When he comes back with her, he jokes about how he mistreated her. Then we get the exchange quoted in Extract 1.3.

Extract 1.3

153 A: maar goed het bloedgehalte is zes komma acht,
153 A: but anyway the blood level is six point eight
154 A: dat is duidelijk te laag.
154 A: that's clearly too low
155 M: o::h
155 M: o::h
156 A: 'hh dus daar e:hm
156 A: 'hh so there u:hm
157 M: (dat) zal wel een grote oorzaak d'r van zijn.=
157 M: (that) may well be a large cause of it
158 A: =dat denk ik.
158 A: =what's what I think
159 (0.4)
160 A: mocht nu blijken=
160 A: in case it would appear
161 A: =>dat ze ondanks het feit dat ze staaltabletten krijgt=
161 A: that she in spite of the fact that she gets iron tablets
162 A: =toch zo slap-=
162 A: just as limp-
163 A: =(d'n) wil ik wat verder kijken,
163 A: then I want to look further
164 A: maar (n-) in eer[ste instantie hou ik het hierop,=
164 A: but in the fir[st instance I stick to this
165 M:                           [n ja:?
165 M:                          [nyes:?
166 M: =dat 't echt eh=
166 M: that it really
167 A: =ja:=
167 A: yes
168 M: =ja dat dacht ik-=
168 M: yes I thought so-
169 M: =>daar was ik zelf ook al bang voor (d[at 't)=
169 M: I was afraid of that myself already that it
170 A:                                                                 [jà
170 A:                                                                [yes
171 M: =ze heeft 't wel es >meer hoor? dan eh
171 M: she does have it more often then uh
172 A: ja
172 A: yes

In lines 153-172, the positive result of the blood test is announced and discussed. The mother participates very actively in this, especially in lines 168-171, where she again, as she did earlier in lines 58 and 64-68, let it be known that she has been expecting this diagnosis all along. The GP, again, restricts his engagement with this to minimal acknowledgements (170, 172).

So now we have the official, empirically substantiated, diagnosis 'on the table', which is immediately accepted by the mother as definite (156-157). The physician, however, distances himself a bit, by presenting the diagnosis as 'for the time being' (160-7). In that move, he includes the therapy as if it was already decided on (161). This may be seen as an acceptance of the mother's 'competence', i.e. as accepting that for her, given the diagnosis, the therapy is self-evident. The mother adds that she had been 'thinking' along these lines herself (1968-9), and that her daughter has suffered from this before (171). This may be compared to her earlier avowal of her own ideas, discussed above (lines 64-8), although she now omits details concerning time and the diagnosing physician. Then she continues as follows in Extract 1.4.

Extract 1.4

173 M: kijk >anders kan'k zelf wel beginnen met staal te geven<
173 M: look on the other hand I can begin to give her iron on my own
174 M: (volg'ns mij) >maar je moet het echt lange tijd volhouden<
174 M: (according to me) but you have to sustain it for a long time
175 M: ( [ )
176 A:    ['hhh ja
176 A:    ['hhh yes
177 A: daar zijn >meningen zijn daarover verdeeld.
177 A: opinions are devided on that issue
178 A: d'r zijn mensen die zeggen k-<
178 A: some people say

[Then follows a lengthy explanation of his point of view by the physician]

In lines 173-4, the mother continues her previous expression of her 'thinking' by mentioning the possibility which she apparently has been considering of initiating this therapy herself (173), to which she adds a suggestion of the necessity of long duration (174). The physician takes this up in two parts. First, he mentions that there is a disagreement on the therapy itself, to which he adds his own 'practical' considerations (lines 176-206, not fully quoted here). Then, he takes up the issue of duration (207-247, not quoted), explaining the necessity of building an emergency supply. The mother actively collaborates in these explanations, with informations (184-5), numerous minimal responses and formulations (240, 248-9). Toward the end of this phase, the GP is evidently writing the prescription (244). So the mother's remarks have been used by the physician to initiate an extensive discussion of the logic of the proposed therapy, i.e. iron tablets (lines 173-249). She seems to have 'invited' such an explanation through a well-known 'fishing device', called a 'my side telling' (Pomerantz, 1980). This device allows someone to ask-without-asking, although here the physician does indeed call it a question (208).

After the explanation, the doctor, in collaboration with the mother, prepares for the closing by adding an 'escape clause' to the earlier promise of success; then the actual closing takes place.

I have taken up this consultation in the present context because it seems to show that a patient, or rather a caretaker acting as a spokesperson for a patient, who did have the cognitive resources to state her diagnosis of a blood shortage and request a prescription for iron tablets right away, instead 'plays the game' of the normal form of the consultation, at least up to the points at which the physician announces his conclusions. In so doing she 'ritually' endorses the lay/professional contrast that morally grounds the health care system as it was practised at the time. By revealing her previously available ideas as seconds to the physician's pronouncements, however, she lets it be known that she could have acted otherwise. This may well have been leading the physician to a more extensive explanation of the reasons for his professional actions than he might have been doing otherwise. In so doing, he treats her as able to grasp the grounds and character of his considerations, that is as more competent than just a compliant patient. In a way, he honours her knowledgeability, which she had demonstrated earlier.

I would suggest that this consultation, without in any way being 'representative' of its time, can be seen as demonstrating some of the basic dilemma's that the changes taking place in the 1970s presented to the established normal form of the consultation. The mother displayed her respect for the physician's task by withholding her knowledge until the physician had presented his ideas, while at the same time letting him know that she did have it available all the time. The physician, for his part, seemed a bit reluctant at first, to honour her claims fully, but in the end did respond positively to her 'fishing', although still in a slightly patronizing manner. I would like to suggest, then, that in certain ways this consultation fitted in historical trends that made the normal form of the consultation, based on a firmly established knowledge gap, a little bit less self-evident. The participants in this encounter seemed to be re-negotiating its terms, although in a subdued manner.

Negotiating the 'normal form'2: a case from the 90s

As a contrast to the previous case, I will now take a look at a consultation recorded in the early 1990s, as part of a documentary film on one General Practitioner, working in Amsterdam (7). Again, a mother consults for her daughter. She demands a referral for physiotherapy. Here's a first extract, corresponding to the start of the scene in the film, and apparently also the start of the consultation (8).

Extract 2.1

001 A daag () hallo (xbene.)
001 A  hi () hallo (name?)
002 A hhh
003 A verwijskaart voor fysiotherapie?
003 A referral for physiotherapy?
004 M ja
004 M yes
005 M ze is bij de sportarts geweest,
005 M she has been to the sportsdoctor
006 M ze heeft een schouderblessure.
006 M she has a shoulder injury
007 (.6)
008 M nou heb' die d'r geadviseerd
008 M he has advised her
009 M om dus even therapie te nemen voor een paar keer,
009 M to take therapy for a few times
010 (.7)
011 M heb ik v'ledenweek al opgebeld,=
011 M I have called last week
012 M =maar ik krijg geen verwijskaart.=
012 M but I don't get a referral
013 A =nee dat vind ik ook niet:=
013 A no I don't agree
014 A =dat klopt.
014 A that's right
015 (.8)
016 A ja dat gaat niet even
016 A yes that doesn't just
017 A dat is geen eh geen broodje wat je e[:ve:
017 A that's not a sandwich you ju[st
018 M                                    [nhee::
018 M                               no
019 M nou jha.
019 M well yea
020 (.6)

After a greeting (line 1), the physician seems to repeat a request that has just been communicated to him, possibly by his assistant, or by the mother herself (3). The mother confirms the request (4), continues to explicate its background, an advice from a sports physician (5-9), and adds that she has called last week, but that she did not get a referral (11-2). Then the physician comes in to express his agreement to the apparent refusal (13-4), and adds that that's not the way that is done, like handling over a sandwich (16-7).

So the parties are in conflict right from the start, the mother demanding a referral as a kind of bureaucratic routine, and the physician refusing to hand it 'over the counter like a sandwich'. In several ways, then, this encounter deviates from the Ideal Sequence as discussed earlier. The patient, represented by her care giver, does not start with a description of a problem, but formulates a direct request for a specific service, even if it is only a bureaucratic one like a referral. And the physician does not proceed by an examination of the case, but rather reaffirms an earlier refusal. The rest of the encounter is used to find a mutually acceptable way out of this open conflict. Extract 2.2. represents a first phase of this exploration.

Extract 2.2 (continuous with 2.1)

021 A ik [(xx- xx-)
021 A I (xx- xx-)
022 M    [ik had van de vereniging wel een therapeut,
022 M     I could get a therapist from the club
023 M daar kon zo naar toe
023 M she could go there immediately
024 M zonder verwijskaart.
024 M without a referral
025 A nou () waarom doet ze dat dan niet?
025 A well () why doesn't she do that then?
026 M nou () omdat dat me te ver weg is.
026 M well () because it's too far away for me
027 (3.6)
028 A 'hh hh
029 A (m'die) sportarts geeft geen briefje mee?
029 A the sports doctor didn't give her a note?
030 A schrijft geen briefje?
030 A doesn't write a note?
031 A je zegt van die sportarts vindt dit of dat,
031 A you say that sports doctor says this and that
032 (.7)
033 A was dat voor een sportkeuring?
033 A was that for a sports physical?
034 M jha.
034 M yes
035 M in dat eh
035 in that uh
036 M van de dolfijnen.
036 M from the dolphins
037 A waterpolo.
037 A waterpolo
038 M nee [wedstrijdzwemmen.
038 M no competitive swimming
039 A         [( )zwemmen.
039 A           swimming
040 (2.7)
041 A jha: ik eh
041 A yes I uh
042 A ja ik kan ev-
042 A yes I can ju-
043 A ik bedoel ik loop een beetje uit,
043 A I mean I am overrunning my time a bit
044 A dat snap ik wel,
044 A I do understand it
045 A maar-
045 A but-
046 A dit is dus niet iets wat ik zo maar even doe,
046 A so this is not something I do just like that
047 A kijk dat gaat om om om vijf zes honder gulden.
047 A look it concerns five six hundred guilders
048 M hmm.
049 A snap je dat ik dat niet zo even door het lo[keafgeef,
049 A do you understand that I do not deliver that just like that over the counter
050 M                                                                [(jha:)
050 M                                                           yea
051 A omdat iemand zegt dat er misschien iets eh ()
051 A because someone says that perhaps something uh
052 A met de schouders niet goed zit?
052 A is wrong with the shoulders
053 (1.5)
054 M jhah g'd ze is gekeurd (op) een sport(arts),
054 M yea alright she has been examined by a sportsdoctor
055 M dus voor de rest weet ik het ook niet.
055 M so for the rest I don't know either
056 (.7)
057 A nee maar goed als die sportarts daar zo van over tuigd is,=
057 A no but alright if that sports doctor is so convinced about it
058 A =dan dan denk ik of hij belt me even,=
058 A then then I think either he calls me
059 A = of hij schrijft een briefje,
059 A or he writes a note
060 A over wat hij gezien heeft,
060 A about what he has seen
061 M nou: dat weet ik- daar ben ik ook allemaal niet mee op de hoogte
061 M well I [don't] know that-I am not informed about all that
062 M hoo[r
063 A       [nee maar nou=
063 A        no but well
064 M =ik kom NOOIT bij een dokter wat dat betreft,
064 M I NEVER consult a doctor as concerns that
065 M dat weet je  zelf ook,
065 M you know that yourself
066 M dus wat- hoe of dat zich allemaal afspeelt onderling weet ik ook niet.
066 M so what-how that happens among themselves I don't know either
067 A nee maar snap je wat ik bedoel.
067 A no but do you understand what I mean
068 M jawel:,
068 M sure
069 M maar snap je ook wat ik bedoel.
069 M but do you also understand what I mean
070 M ik kom voor de rest nooit bij een dokter:eh:,
070 M I never consult a doctor for the rest uh
071 M ik zit hier NOOIT!
071 M I sit here NEVER
072     (.4)
073 M [nou en zij krijgt dat advies van die sportarts dat zij therapie-=
073 M well and she gets that advice from that sports doctor she [needs] therapy
074 A [(xxx)
075 M 'hh ze mag ook niet met d'r armen zwemmen,
075 M she is also not allowed to swim with her arms
076 M ze mag op 't moment alleen met d'r benen zwemmen.
076 M she's at the moment only allowed to swim with her legs
077     (1.7)
078 M maar ze kon niet meer trainen,=
078 M but she could no longer train
079 M = want ze moest eh de trainingen onderbreken,=
079 M because she had uh to interrupt the training
080 M =want ze- ze kreeg die  arme:
080 M because she she could not move
081 M kreeg ze niet meer om.
081 M her arms around
082     (2.5)

The mother explains her demand further by saying that she could have had another therapist take care of her daughter through the sports club without a referral (22-4). As the physician asks why she did not take that opportunity (25), she mentions practical reasons, that therapist being too far away (26). It may well be that the mother mentions this bypassed opportunity as an account for her taking the present demand lightly.

The physician, however, asks for details concerning the sports doctor's advice: that he didn't give a letter (29-30) and what kind of physical it was (31-9). Then he further explicates his reluctance to comply with her request: he cannot just give a referral, costing a large sum of money, because someone else had said the girl needs it (45-52). The mother says that she does not know anymore about it (54-5). The doctor continues with complaints about the fact that the sports doctor hasn't contacted him (57-60), but the mother claims ignorance as to professional procedures because she 'never' consults (61-6). Then, in remarkable parallel, the physician and the mother request each other's understanding (67, 69).

The mother continues to stress that she 'never' consults (70-1), that she just got this advice (73), and that her daughter is not allowed to use her arms when swimming, because she cannot get them around (75-80).

Extract 2.3

083 A ja ik zou toch het liefste haar ehm::, (.4)
083 A yea I would just the same prefer her uhm
084 A kan ze niet alleen even terugkomen?
084 A is it not possible for her to come back alone?
085 A dat ik haar even bekijk?
085 A that I take a look at her?
086    (.8)
087 M jh[a () dan moet ze zitten wachten.
087 M yea () than she has to stay and wait
088 A    [je hoeft dan niet mee?
088 A    you don't have to come with her?
089 A ik bedoel eh:,
089 A I mean uh
090 (1.1)
091 D dan wacht ik hier wel.
091 D than I wait here
092 M oké ga jij (ma')zitten  wachten,=
092 M okay you can sit and wait
093 M =ik ga Marvin [nu halen.
093 M I go to get Marvin now

The physician makes the first move to reach a compromise, by proposing that the girl can come back alone for a physical examination (83-5). It is remarkable that he starts with formulating a preference, rather than a requirement (83), and that the option is formulated in terms of a minimal investment on the mother's part, as the girl can come alone (84, repeated in 88), while he would 'just' take a look at her (85). The mother seems rather unwilling to give in (87), but the daughter adds that she is willing to wait (91). The mother accepts that still reluctantly (92) and announces she will go and get Marvin, probably her son (93). The physician, however, continues to account for his refusal:

Extract 2.4 (continuous)

094 A [ik
094 A I
095 A ik- moet je horen,
095 A I- listen
096 A ik kan-
096 A I can-
097 A ik wil  niet zomaar,
097 A I don't want just like that
098 A ik stuur je dan naar een therapeut,
098 A I would send you to a therapist
099 A voor een behandeling,
099 A for a treatment
100 A van iets dat ik zelf niet gezien heb.
100 A of something I haven't seen myself
101 (.5)
102 A snap je?=
102 A do you understand?
103 A da- dat doe ik niet.
103 A tha- that I don't do
104 (.7)
105 A ik weet niet eens wat voor therapie,
105 A I don't even know what kind of therapy
106 A gewone fysiotherapie,
106 A ordinary physiotherapy
107 A mensendieck,
107 A mensendieck
108 A of het iets van je houding is,
108 A or if it has something to do with your attitude
109 A of iets anders,
109 A or something else
110 A dus dat eh::
110 A so that uh
111 (.4)
112 A daar kijk we zo wel even naar
112 A we'll take a look at it in a moment
113 A en dan spreken we af dat ik dat- da- dat het wel in orde komt.
113 A and then we agree that I that tha- that it will turn out alright
114 A maar dan kijk ik zo wel,
114 A but then I will take a look in a moment
115 A laat (haar) maar even wachten.
115 A let her wait for a moment
116 A ja?
116 A yes?
117 M ma: ik ga weg?
117 M bu- I go away
118 A ja.
118 A yes
119 D ik wacht hier wel.
119 D I will wait here
120    ((deuren en voetstappen))
          ((doors and footsteps))

Although a solution has been reached, the physician goes to some length to again explain his position (94-110), stressing the necessity for seeing the girl's condition himself, in order to reach a specific referral (105-9). And, although he announces a physical examination (112, 114), he already promises a positive outcome (113). He then asks for her agreement (116), which she implies but not really supplies, announcing again that she will go away (117), which she does after the physician has accepted that (118) and the daughter has again said she will wait. Then the mother leaves without greeting (120).

What to my mind is most remarkable in this extract is the contrast between on the one hand the almost pleading tone of the physician and on the other the persistent anger of the mother, who is not willing to politely accept the offered alternative, while her daughter does so. The film continues as follows:

Extract 2.5 (continuous)

121 NR ben je boos?
              are you angry?
122 A jha:a
123 A ik ben boos.
           I am angry
124 A ja ik vind het gewoon eh eh gedram.
           yes I think it is just uh uh nagging

After the mother has left the room, the film maker asks the physician whether he is angry (121), which he confirms (123) and explains (124), characterizing the mother's behaviour as 'nagging'. In the film, this scene is followed by an extract from an interview of the filmmaker with the doctor in his home, in which he talks about troublesome patients and his own affords to reaffirm his own 'rules'. Then we get an extract from the scheduled consultation with the daughter, in which the physician, after a physical examination, grants her a referral for four or five sessions.

So we can say that the episode ends with the demanding mother getting what she was after, although at the terms set by the physician, a physical examination of the daughter's case. In terms of their overall comportment, however, it seems that the physician has given in, while the mother has refused to budge.

As discussed earlier, the Ideal Sequence has implications in terms of the category-bound activities and competencies which the parties have as members of a Standardized Relational Pair. The patient, and by extension his or her spokesperson, is expected to express experiences and concerns in lay terms, but has to leave any further cognitive work to the physician, whose professional task it is to investigate the case and propose diagnoses and remedies.

Within the Dutch medical system, the GP acts as a gate-keeper for all medical services. So in principle, a patient presents a problem and the GP then, mostly after an examination, decides whether to treat the problem himself or herself, or to refer the case to a specialist of one kind or another. For clear cases, such as a routine visit to an ophthalmologist, a prior examination by the GP may be skipped. In the case discussed above, the mother acted on such a basis, directly asking for a referral, at first over the phone, and later in person. On her account, she is entitled to such a direct approach because the therapy request is based on professional advice, by the sports physician. She does not have any documents to proof this claim, however.

In the SRP of 'doctor' and 'patient', two different contrasts (or sub-SRPs) are combined: on the one hand they are 'expert' and 'lay person', but on the other 'service provider' and 'service recipient'. What the mother in the first case did, was, in a way, to officially honour the first sub-SRP, while 'hiding' the second. In the second case, however, it was the second sub-SRP that was foregrounded by the mother, while the physician insisted that the first was also relevant. He did not want to be reduced to being 'just' a service provider.

Discussion: history as a contingent achievement

As indicated earlier, the two cases discussed above are not to be taken as 'representative' of the 1970s and the 1990s respectively. They are both unique events which were in some ways rather unusual. What cannot be denied, however, is that they did happen in these respective decades and therefore can be taken as demonstrating their time-bound possibility. They did not only differ in their location in time, however, but also in space. The first case was recorded in a semi-large village in the Dutch countryside, the second in a popular Amsterdam suburb. And there are other differences as well.

What, then, is the significance of these cases for my general argument? On the basis of my global corpus-based knowledge of GP consultations in the 1970s, I can say that the first case was indeed a bit unusual at the time, in the way in which the mother handled the consultation as a delayed and subdued, but still explicit demonstration of her pre-existing 'medical' knowledge. It would be very hard, however, to imagine the second case happening in those days, while it was probably still a rather exceptional one in the 1990s.

The normal form of the consultation, that I have specified in terms of an Ideal Sequence, is not just a practical arrangement for organizing a medical encounter, it has 'deep' categorical implications, defining one party as 'host', 'service provider' and 'expert', and the other as 'guest', 'service requester/recipient' and 'lay person'. The local relevance of these SRP's is variable. The host/guest SRP, for instance, recedes in the background when a complaint or request is voiced by the patient, to return at the closing of the encounter. Within the medical part of the consultation, it is the doctor/patient SRP that is obviously relevant, but which of the two sub-SRPs takes precedence - service provider/requester or expert/lay person - is often less clear.

In both of the case discussed before, the normal form of the consultation, with its categorical implications, is contested in some way by the patients' mothers, while it is defended to a certain extent by the physicians. And furthermore, it seems to be the balance between the two sub-SRPs that is at stake. This would suggest that a historically observable 'erosion' of the normal form, that seems to have taken place over the last few decades, can be seen as an effect of patients no longer accepting that 'asymmetrical' format and/or its implications.

In my corpus from the 1970s, however, there are a substantial number of cases in which a deviation from to the normal form was initiated by the physicians, while their patients at times seemed to resist it. This happened in two different kinds of circumstances. Sometimes physicians tried to acquire a patient's acceptance of a diagnosis or a treatment decision by explicitly asking the patient for his or her opinions or preferences. This occurred especially when the physician was faced with a dilemma or when his conclusions seemed to differ from those 'projected' by earlier contributions from the patient. These efforts by physicians to share the responsibility for the consultation's outcome with their patients was quite often resisted by the latter, referring at times to the expertness of the doctor (cf. Heath, 1992, Ten Have, 1995b). A second kind of circumstance in which the GP initiated a deviation from the normal form occurred when the case seemed to involve conditions of a psycho-social kind, and the physician started asking the patient for his or her own perspectives, experiences or explanations. In earlier work (1987, 1989), I have conceptualized such events as a problematic convergence of two different formats, the normal form of the consultation and Therapy Talk. Again, an effort to shift responsibilities from the physician to the patient seems to have been involved, at times accounted for in terms of the patient's 'expertise' regarding his own experiences and circumstances.

As I suggested earlier, ethnomethodology is committed to always take into account the uniqueness of each separate situation as a local members' accomplishment. But at the same time, it is focussed on the reflexive accountability of the actions that make up such situations. This means that actions are designed to be observable, reportable, repeatable, and recognizable as 'the same as' or 'similar to' other members of their class, as, for instance a greeting, a complaint, or whatever. In other words, while ethnomethodology stresses the moment-by-moment constitution of social life, it at the same time suggests that this is a routine accomplishment (cf. Schegloff, 1986 on telephone call openings). With this Janus-faced characteristic of ethnomethodology in mind, I want to reconsider the significance of my two cases in terms of an observable historical change in the routines of medical practice, a change that can be glossed as an erosion of the normal form of the consultation.

For knowledgeable participants in an event of a particular type, the normal form for that event is both a product and a resource. It is a product of their previous experiences with that type of event. And it is a resource by being a frame of reference, a schema of orientation and action, for each newly encountered and co-produced instantiation of that type of event. For the consultation, the normal form is available for doctors and patients to coordinate their interaction as a concerted achievement of its non-remarkableness, its ordinary, business-as-usual character. The normal form of the consultation is not a strict scenario, however, it is not an algorithmic program, but rather a rough and open schema, that offers options or action-slots in a 'logical' but not strictly prescribed order. Therefore, participants can 'follow' the normal format of an event, but at the same time challenge its 'normality' to a greater or lesser extent. That is, they can use the particularities of their case to make the normal form in some respect less relevant, and therefore less binding, at least on this occasion (cf. again, Schegloff, 1986 on telephone call openings, and Ten Have, 2002 for a further discussion).

In the two cases considered above, we could observe how the mothers accomplished such a challenge. In the first case, the mother used the pronouncements of the physician as a stepping-stone for reports on her thoughts, suspicions and suppositions. In other words, she used the discussion-parts of the various phases of the consultations to air her ideas which she had previously held back in order to grant the physician his due 'first turn', in accordance with the expert/lay person SRP. In so doing, she showed her respect for the normal form, and for the professional standing of the physician that is implied with it, but at the same time, she partly undermined its rationale, i.e. that she would not know what was wrong with her daughter and what to do about it. In the second case, the actions of the mother were much more devastating for the normal format of the consultation. Not only was she aggressive rather than polite - undercutting the host/guest SRP, but she used her report on the sports doctor's advice to skip most of the characteristic phases of the Ideal Sequence, trying to strip it to a bureaucratic service encounter, or, as the physician suggested, similar to buying a sandwich - based on a 'pure' service SRP. In this way, she did not show any respect for the physician's professional standing, to be enacted in an examination of the case, based on her lay reporting of symptoms, and leading to his knowledgeable diagnosis and treatment decision. The physician made it very clear, although in a polite, almost meek manner, that this was not acceptable to him. As he fought back, he succeeded at least in saving a semblance of the normal form, although he seemed to give in at the substance of the service demand.

The normal form of the consultation must have emerged as the product of a large number of encounters between clients and providers of medical and related services. The details of those events are no longer available for study. Examples of fully functioning normal form consultations, and of encounters in which that format is more or less subtly undermined, are available however. They deserve further study.


* Revised version of a paper read at the conference ‘Structure and Emergence of professionalized “Praxis”’, J. W. Goethe-Universität, Frankfurt, Germany, September 26 – 28, 2001

2. My characterization of ethnomethodology is a personal and selective one, constructed for the rather specific purposes of this exercise. Among the many other sources, I would specifically suggest to consult Heritage (1984) for a broad scholarly overview, Button (1991) for a collection of essays dealing with ethnomethodological ways of treating some of the classic themes of the human sciences, and Lynch (1993) for some pointed and polemical discussions confronting ethnomethodology and the sociology of scientific knowledge.

3. Cf. Garfinkel (1967): 11-8, and Atkinson (1978) for some early efforts in these directions.

4. See Ten Have (2001b) for an overview; and Boden & Zimmerman (1991) and Drew & Heritage (1992) for discussions and examples.

5. See Ten Have (1995a) for an overview of 'medical ethnomethodology'; cf. also Ten Have (2001a)

6. That paper is available at:; the full transcript of the consultation can be consulted at:

7. "IK HEB MIJN OOG GESLAGEN, AAN HET BED", by Netty Rosenfeld, broadcast by VPRO Television in 1993.

8. Working with materials from a professional film is hazardous because one does not know for sure whether the displayed interactions are complete and presented in the correct order. For the current analysis, this does not seem to be a serious problem.


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